Overview
Medicare does cover Ankle Foot Orthoses (AFOs) that are permanently attached to a shoe (and associated modifications). See Section D. This generally envisions single and double uprights. The attached shoe is an integral part of these types of orthoses and therefore, Medicare covers them, too. The attached shoes will often wear out before the orthosis. In order to continue to function properly, the orthosis must be transferred and attached to a new shoe. These transfers can be done by a practitioner who is different from the practitioner who dispensed the original orthosis.
A caliper plate is a metal rectangular structure that is inserted between the midsole and the outsole (or heel) of a shoe, and is attached to the shank of the shoe. It extends medially and laterally within the shoe and is exposed on the medial and lateral sides of the shoe. These exposed sides have an opening (channel) into which the metal stirrups (uprights) can be inserted. The top portion of the metal stirrups are connected to the main body of the orthosis, generally via a calf strap (see chapter DB).
A “solid stirrup” is a metal structure that is inserted between the midsole and the outsole (or heel) of a shoe, and is attached to the shank of the shoe. A “solid stirrup” has the caliper plate and stirrups incorporated into one solid piece. The top portion of the “solid stirrup” is connected to the main body of the orthosis. See chapter DB. These transfer codes envision current technology for transferable AFOs. As future technologies for transferable AFOs are developed, new corresponding transfer codes will need to be developed.
The main codes currently in existence are:
L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW The PCC recommends the following clarifications:
PCC/New Description Explanation
L3600 Transfer of a permanently attached orthosis component from one shoe to another, existing caliper plate, per foot.
This code is used when the caliper plate is saved and reused. This code is just the labor component. It is used when the single or double upright orthosis is preexisting. Medicare does pay for this code, so practitioners need to stay abreast of Medicare guidelines and, to the extent that they differ from PCC guidance, the Medicare guidelines control for Medicare.
Old Description L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING
PCC/New Description Explanation
L3610 Transfer of a permanently attached orthosis component from one shoe to another, new caliper plate, per foot.
This code is used when a new caliper plate is installed. This code includes both the caliper plate and the labor component. It is used when the single or double upright orthosis is preexisting.
Medicare does pay for this code, so practitioners need to stay abreast of Medicare guidelines and, to the extent that they differ from PCC guidance, the Medicare guidelines control for Medicare.
Old Description
L3620 Transfer of a permanently attached orthosis component from one shoe to another, existing solid stirrup, per foot.
This code is used when the solid stirrup is saved and reused. This code is just the labor component. It is used when the single or double upright orthosis is preexisting.
Medicare does pay for this code, so practitioners need to stay abreast of Medicare guidelines and, to the extent that they differ from PCC guidance, the
Medicare guidelines control for Medicare. L3630 TRANSFER OF AN
ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIR- RUP, NEW
L3630 Transfer of a permanently attached orthosis component from one shoe to another, new solid stirrup, per foot.
L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW
L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING
This code is used when a new solid stirrup is installed. It includes both the solid stirrup and the labor component. It is used when the single or double upright orthosis is preexisting.
Medicare does pay for this code, so practitioners need to stay abreast of Medicare guidelines and, to the extent that they differ from PCC guidance, the Medicare guidelines control for Medicare.
FAQ:
Q: Does Medicare currently have a specific code for Custom Shoes Attached to a Brace?
A: No. Currently, Medicare has a defined code for OTS shoes attached to a brace, but does not have a defined code for Custom Shoes attached to a brace. This creates a complicated billing situation. Until Medicare can harmonize this particular policy, the PCC believes a separate code is required for Custom Shoe attached to a brace. For more information see chapter BI.
Please note that the following codes are commonly used in conjunction with these codes:
L3224 ORTHOPEDIC FOOTWEAR, WOMAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS)
L3225 ORTHOPEDIC FOOTWEAR, MAN’S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) For a covered brace, the shoe attached to the brace is also covered, as are any modifications attached to that shoe. Many of these braces require a steel shank. If you include a STEEL shank inside the rocker, you should also code L2360. If you do a carbon shank or fiberglass shank, or other similar material, you should code L3649 (L3BBC) with a description “Like L2360, but carbon fiber (or fiberglass)”. PCC has decided that this code has both the labor and materials component included for this incremental step.
CHAPTER BG: OFF THE SHELF SHOES-PEDIATRIC